light exposure can exacerbate melasma.21 Photoprotective agents, including sunblock, are effective in preventing new lesions of hyperpigmentation.22 However, sunscreen was not as frequently prescribed in persons of color than in white patients. Sunscreen was prescribed 17% of the time in blacks and 7% in Asians and 32% of the time in whites. The melanocytic activity as well as the total melanin content is higher in darker skin.23 Melanin has an inherent photoprotective role from its physical shielding effect that scatters the UV rays and reduces UV penetration through the epidermis.24 Also, lighter skin has the tendency to burn more than darker skin. Perhaps these are some of the reasons why dermatologists may not recommend sunscreen as frequently in African American and Asian populations than in Caucasians. Nonetheless, sunscreen is effective in treating and preventing hyperpigmentation, and should be recognized as a vital therapy, particularly in persons of color.
Combination therapy may be underutilized in black patients compared to white individuals. Blacks were given combination treatment 14% of the time compared to whites who were prescribed a combination agent 21% of the time. However, Asians were prescribed a combination agent 29% of the time and were 26% more likely than their non-Asian counterparts
to receive combination therapy. It may be possible that Asians seek treatment for hyperpigmentation disorders more than other races. This may correspond to our data, which demonstrates Asians with the highest number of visits per 100,000 population for dyschromia. Studies show that combination treatment for hyperpigmentation yields better results than monotherapy.25-27 In combination therapy, tretinoin
reduces the atrophy of the corticosteroid and facilitates the epidermal penetration of hydroquinone.28 In one study, a triple combination cream of tretinoin, hydroquinone, and fluocinonide acetate for melasma had a better response than double combination or monotherapy.29 The Kligman’s formula,
which consisted of a tretinoin 0.1%, hydroquinone 5% and dexamethasone 0.1% demonstrated significant improvement compared with single or double medications for hyperpigmentation.
30 Combination agents may be underutilized in darker skin types because of the risk of unwanted side effects, such as exogenous ochronosis, irritation, hypopigmentation of the surrounding skin (halo effect), contact dermatitis, and leukoderma.31 The safety profile of hydroquinone may be questionable due to untoward side effects.32 However, it is suggested that the first line therapy for hyperpigmentation in persons of color be a combination of hydroquinone and sunscreen to prevent further darkening of the dermatoses.31 Due to potential risks of hydroquinone as stated above, the use of novel agents have been prompted and may be a good alternative for hyperpigmentation therapy.
Limitations include that the NAMCS unit of analysis is the patient
visit, which does not allow direct estimation of prevalence. Specific pigmentary disorders could not be distinguished from our database. The diagnosis of dyschromia (ICD-9 codes 709.00 and 709.09) is a non-specific condition that includes various pigmentary disorders. Various ethnicities or races may have differing causes of dyschromia and thus, the treatment may differ among races depending on the cause of the dyschromia.
Dyschromia can be distressing to an individual and skin type is taken into account when considering the proper treatment. Combination therapy has been shown to offer best results compared with other medications alone.9,30,33 Patients with darker skin may be more prone to hyperpigmentation from inflammatory disorders such as acne or pseudofolliculitis barbae, and thus prevention should be addressed with sunscreen and combination therapy.34 Newer agents are becoming more popular in treatment of melasma and other hyperpigmentary disorders; however hydroquinone, topical steroids, and retinoic acid are still among the top 10 medications prescribed across all racial/ethnic groups. Treatment for dyschromia is likely influenced by skin type, and thus different ethnic or racial groups are taken into account when prescribing an agent. Combination therapy, which offers the best results for dyschromia, may be underutilized in certain racial groups, such as blacks and Hispanics, and thus a combination regimen should be considered when treating various conditions of hyperpigmentation.
DISCLOSURES
The Center for Dermatology Research is supported by an unrestricted
educational grant from Galderma Laboratories, LP. Dr. Feldman is a consultant and speaker for Galderma, Connetics, Abbott Labs, Warner Chilcott, Centocor, Amgen, Photomedex, Genentech, BiogenIdec, and Bristol Myers Squibb. Dr. Feldman has received grants from Galderma, Connetics, Astellas, Abbott Labs, Warner Chilcott, Centocor, Amgen, Photomedex, Genentech, BiogenIdec, Coria, Pharmaderm, Ortho Pharmaceuticals, Aventis Pharmaceuticals, Roche Dermatology, 3M, Bristol Myers Squibb, Stiefel, GlaxoSmithKline, and Novartis and has received stock options from Photomedex. Dr. McMichael is a consultant for Johnson and Johnson, Proctor and Gamble, Galderma, and Gunthy-Renker. Dr McMichael is an investigator for
